Scapular winging: evaluation and treatment

Scapular winging is a rare disorder which may cause pain, reduced shoulder strength, limited range of motion, and cosmetic deformity as a result of abnormal scapulothoracic posture and motion. Disruption of the scapulothoracic stabilizers will cause dysfunction in the motion of the scapula. Various etiologies of injury to the long thoracic or spinal accessory nerve have been reported as potential causes of scapular winging.

Scapular winging is a rare and potentially weakening disorder with several causative factors. Diagnosis is mainly clinical and relying on suspicion. Early diagnosis and surgical intervention is known to improve patient outcomes. Blunt trauma or stretching injury to the nerve imply conservative management options as first-line therapy. Without evidence of any direct nerve laceration injury, nonsurgical management should typically be attempted for twelve to twenty- four months, provided that there is evidence of some progressive nerve recovery.

Causes may be trauma injuries which may cause traction-type insults to a nerve. Injuries caused by treatment or diagnostic procedures may injure the long thoracic nerve, the most common being the resection of the first rib. Other known causes are cervical lymph node biopsies or oncologic resection.

Initial nonsurgical management includes a physical therapy program with the aim of preventing the loss of range of motion, improvement of strength and function of the compensatory muscles. A physical therapy program including an individualised home treatment program is beneficial. Activity modification should also be implemented, with a focus on avoiding elevation of the arm above the shoulder level. A scapular brace may also be used during rehabilitation. The effectiveness of these programs however depend on patient compliance.

In case of failure to resolve the issue during twelve to twenty-four months of conservative management (demonstrated by EMG) dynamic muscle transfer surgery should be considered. Nonoperative treatment options have higher success rates for serratus anterior palsies compared with trapezius palsies.

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